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riii%ji APPLICATION FOR PERMIT( - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009 , STOC%TON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR FROM DATE TS4IrM (Complete in Triplicate) Application in hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application Is made in compliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ZDq-X68-'2160 Job Address l50 N05PITL ?A-Lf L A- Ah1F- � � City_ MLot Site/Acreage 1 STEVE KEE"Ftr` SAN3onflUW Ceuu�Y couP:TEg0ItSE- xo Ybwf Owner's Name _STTE.\)E F RERr —"—> Address 150 HoSPrrAr_ LANE Phone Zo - '4R 6611 SPEtcTvl F�VpLoCh710^I Contractor 31M kLEIE1FEt_J F� Address 2825 EASr-M`�fZTtE ST. 'icennssee No. PhoneZ - 65-8712 W` r FR-- TOT DESdRGtTt6N$-0u SOIL gbr W65 UMP-JNB�Att�fbff-� OTHER Mnn3-t pctlz�u � DIS T: SEPTIC TANK + 5D SEWER LINES 2.5 DISPOSAL FLD�-��p�-• PROP. LINE45044 FOUNDATION IO AGRICULTURE WELL "+S OTHER WELL PITS/SUMPS"; TENDED USE -S=rE OF AEa- PAOULEpf ARfq- ❑ Industrial ❑ Open Bottom ❑ Manteca Oia. of lV�lell Exc vation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack D Trac Type of Caaiuw� N A Y 9 Specilicanonz_C�f PublicLDDelta Depth of Grout Seal Q Type of Grout k ❑ Irrigation 25 Aopfoa. Depth Eastern Suffice Seal Installed by KLEtNFEL11E.lz Repair Work Done U Typa of Pump N H,P. N State Work one _ Wel estructlon ❑ ell Diameter Sealing Mater a1 i Depth SotL A,SF5, Depth Tiller Material i Depth 5ftrk P/L(- TYPE OF SEPT C WORK. NEW INSTALLATION 17 REPAIR7ADOI TION q DESTRUCTION Cl (No septic system permitted if public "war is }!-�Y available within 200 feet.) Installat 1'Nrve: Residence _ Commercial _ Ocher Number of living unite _ Number of bedrooms Character of soil to a depth of 3 feel: Water cable depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE I ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ SEEPAGE PITSJ I Depth Size Number SUMPS N U Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 1 hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale lows, and rules and regulations of the Sen Joaquin County Home owner or licensed agent's signature candles the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring of subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's comber". tion laws Of 107H The applic Ffiu cai for MI fuYsd inspections. omplete (swing verse side. -/ Signed �' Tilos: �� C'a��' r, /�( Date: l ( ,,FO1R,f4DPEPARTMENT USE ONLY Application Accepted by - lMi Date t;- CZ �L,,Ar(ea Pit or Grout Inspection by "I�'�V�L�(.((�r��!Q. r �4( Final Inspection by� �� (" "' Data Additional Comments Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STUCKTON, CA 85201 2� r INFO AMOUNT DUE AMOUNT nEMITTEO CASN RECEIVED By DATE PERMIT NO. IAIV. ,,,, 3 , ori o� p o l r, EN:r al